Skip to main content

The PSNet Collection: All Content

The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.

Search All Content

Search Tips
Published Date
Original Publication Date
Original Publication Date
PSNet Publication Date
Narrow Results By
Search By Author(s)
PSNet Original Content
Commonly Searched Resource Types
Displaying 1 - 7 of 7 Results
Kane RL, Huckfeldt P, Tappen R, et al. JAMA Intern Med. 2017;177:1257-1264.
Reducing acute care hospitalizations from nursing homes is a patient safety priority. This cluster-randomized controlled trial compared a multimodal quality improvement intervention at long-term care facilities and found no difference in the rate of acute care hospitalizations compared to usual nursing home care. These results emphasize the challenge of improving safety outcomes in real-world clinical settings.
Cabral RA, Eggenberger T, Keller K, et al. AORN J. 2016;104:206-216.
Surgical team communication is an important element of safe care. This project report describes how one hospital implemented a checklist program that utilized time outs and debriefings to support transparency and improve surgical teamwork behaviors.
Geiger-Brown J, Rogers VE, Trinkoff AM, et al. Chronobiol Int. 2012;29.
Nurses' working conditions have been shown to affect patient safety. This study found that nurses working successive 12-hour shifts accrue significant sleep debt, regardless of whether these shifts occur in the daytime or at night. Further work should examine the effects of nurse fatigue on patient outcomes.
Shamliyan TA, Kane RL. J Patient Saf. 2016;12:89-107.
Prior studies have shown that older patients are particularly vulnerable to medication errors. This cohort study documents a marked increase in both hospitalizations due to adverse drug events and in Medicare patients between 2000 and 2008. During that time frame, the incidence of in-hospital adverse drug events and the severity of harm experienced by patients rose as well.
WebM&M Case December 1, 2013
… information necessary to prevent medical errors. … Joseph G. Ouslander, MD … Professor and Senior Associate Dean for … Services. [Available at] 15. Ouslander JG, Lamb G, Tappen R, et al. Interventions to reduce hospitalizations …
Shamliyan TA, Duval S, Du J, et al. Health Serv Res. 2008;43:32-53.
While computerized provider order entry (CPOE) is widely recommended, studies of CPOE have produced varying estimates of its effect on medication errors, and recent research has raised the concern that unintended consequences of CPOE may outweigh its benefits. This systematic review sought to determine the overall effect of CPOE on medication safety across different hospitals and patient populations. Overall, CPOE did reduce medication errors in both adults and children, but patient outcomes were not affected. The authors note that variability in error measurement and the types of CPOE systems used makes it difficult to generalize the results of specific studies. A prior review also found that health information technology in general, including CPOE, was not associated with significant improvements in patient outcomes.